Principlism and its Discontents – A Review of Raanan Gillon’s Philosophical Medical Ethics

I think I engaged more with ethics as a student of computer science than I did as student of medicine (worryingly I also wrote more essays in my computer science degree than my medical one). Epstien’s Case of the Killer Robot [1] has become standard fare for engineering degrees. The case centres around whether the coder is morally or legally responsible for when his* malfunctioning code of an assembly line robot kills a factory worker. Whilst at medical school, I never had the opportunity to interact with ethics in the same way. We covered the requisite law and anytime we had a lecture on medical ethics someone trotted out the four principles (autonomy, beneficence, non-maleficence and justice) and the conversation moved on. Never were we told whose principles these were, why it was we followed them or what to do when the principles conflicted. They were presented as some sacred medical law and reiterated frequently through both my foundation years and my vocational general practice training. Any discussion of ethics with medical colleagues seem to end with the conclusion that right and wrong were all relative. Occasionally, when dealing with patients too frail or far-gone for medical intervention where some wit might quote the famous lines from Arthur Hugh Clough’s poem ‘The Latest Decalogue’:

“Thou shalt not kill; but needst not strive
Officiously to keep alive”

Most doctors especially at the start of the careers seem to try and find a happy mix between autonomy and beneficence with the latter two principles being of lesser concern. It was not until I started my masters in bioethics that I understood the origins of principlism and learned of the great disagreements with it. I began to see the philosophical underpinnings of medical ethics and developed a profound sense of self-satisfaction with this seemingly modern frontier that I was exploring. My satisfaction lasted only as long as it took me to stumble across philosopher-physician Raanan Gillon’s wonderfully concise book entitled “Philosophical Medical Ethics”. Written over thirty years ago, Professor Gillon had outlined (in language even a medic could understand) many of the philosophical tenants that shape our ethical decision-making process.

Gillon starts his book with the real life case of Dr Arthur who prescribed only dihydrocodeine and nursing care for a child born with Down’s syndrome who had been rejected by his mother; Gillon uses the case as a way to explore the different dilemmas that arise. We take a tour through the major philosophical pillars of medical ethics. Utilitarianism, virtue ethics, deontology, truth telling but ultimately Gillon is a firm believer in the superiority of principlism.

“But I think the four principles should also be thought of as the four moral nucleotides that constitute moral DNA—capable, alone or in combination, of explaining and justifying all the substantive and universalisable moral norms of health care ethics and I suspect of ethics generally! Certainly that has been my hypothesis for many years, indeed since I first read the first edition of Principles of Biomedical Ethics. With increasing confidence over the intervening years I have routinely asked audiences and readers, be they philosophers, doctors, or anyone else who will listen or read, to offer disproof of the hypothesis by arguing either against the moral acceptability of any one of these four prima facie principles or by arguing for the need for additional normative and universalisable moral principles that can’t be explained and justified by one or some combination of the four. Suffice it to assert that I have so far not heard or read or thought of plausibly argued counterexamples. Let me renew this Popperian request for disproof [2].”

Gillon is one of the most eloquent advocates of principlism. However, it still ultimately fails to convince me. Nevertheless by the end of the book (and hearing him speak once) I no longer have the same hostility towards it. More importantly, Gillon’s work is one of the best introductory texts to philosophical medical ethics.

*Whilst I do in general endeavor to use gender neutral pronouns we had less than ten females in a class of over two hundred